Provider Demographics
NPI:1255323663
Name:GHANDOUR, OMAR F (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:F
Last Name:GHANDOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7601 SOUTHCREST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4739
Practice Address - Country:US
Practice Address - Phone:662-772-2130
Practice Address - Fax:662-772-2131
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS222172085R0001X
TN367792085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4046696OtherBLUE CROSS BLUE SHIELD
TN3876529Medicaid
AR99465OtherBLUE CROSS BLUE SHIELD
MS00127062Medicaid
AR148872001Medicaid
7160133OtherAETNA
H04855Medicare UPIN
MS00127062Medicaid
MS00127062Medicaid
AR99465OtherBLUE CROSS BLUE SHIELD